Coronary Artery Disease in the CHD Community!

This new episode of Heart to Heart with Anna featured Guest, Dr. Fred Wu from Boston Children's Hospital and he interacts with a live, studio audience to answer their questions regarding coronary artery disease in adults born with congenital heart defects. Tune in to hear why this situation is being talked about now more than ever before, what you can do to prevent or reduce the likelihood of contracting coronary artery disease and what congenital heart defects are most prone to having problems with coronary artery disease.

Transcript

spk_1:   0:00
We've had well over one and 1/2 1,000,000 adults in the U. S. Living with congenital heart disease for some time now, and many, if not most of those individuals will develop coronary artery disease.

spk_0:   0:18
Welcome to heart to heart. With Anna, I am an Edge, or C and the host of this program. This is the final episode of Season 13. I am very excited about today's show because we will be featuring a very special doctor. Today's show is entitled Coronary Artery Disease. In a congenital heart defect community, Dr Fred Wu is board certified in pediatrics, internal medicine and cardiovascular disease. After receiving his doctor of medicine degree from the University of Michigan Medical School in Ann Arbor, he completed a combined residency program in pediatrics and internal medicine at the University of Minnesota Medical Center and a fellowship in cardiovascular disease, also at the University of Minnesota. In 2007 he completed in Advanced Fellowship in adult congenital heart disease and pulmonary hypertension at Harvard Medical School, and stayed on to become a faculty member of the Boston Adult Congenital Heart and Pulmonary Hypertension Program. Dr. Wu has received a Sanofi Aventis fellow travel Award for Research, a teaching award from the Harvard Medical School Academy Center for Teaching and Learning Excellence and Grant Funding through Boston Children's Hospitals. Innovation and Digital Health Accelerator for research into innovative or purchase to the management of patients with single ventricle physiology. I appreciate you coming on the show. Thank you, Dr Will. Members of the CHD community have to take into consideration problems with the major vessels and structures of their heart. But it's come to our attention now that having a congenital heart defect does not preclude a person's chances of developing coronary artery disease. So can you tell us if people with CH desire more at risk for developing coronary artery disease?

spk_1:   2:06
Yeah. In fact, myocardial infarction, which is the technical term for a heart attack, has been the leading cause of death and adults with non cyanotic congenital heart defects in the US for quite some time now for about the last 30 years. And that's largely because so many more people with CHD are now living longer and reaching an age where they face an increased risk of acquired cardiovascular diseases such as coronary artery disease. In addition to the unique issues that are the result of their congenital defects. Now, whether these individuals are at a higher risk for coronary disease compared to their same age peers who don't have congenital heart disease, I think is less clear. There's some studies that have suggested that people with CHD are at high risk for developing coronary disease at earlier ages. But in most cases, people with CHD who do have coronary disease usually have identifiable risk factors such as high blood pressure, high cholesterol, diabetes and so forth. But a study that was recently published by the A C H D group at Stanford did find that even after adjusting for what we know to be risk factors for coronary disease, adults who are born with CHD do seem to be at a higher risk still, for coronary disease compared to their peers

spk_0:   3:14
in a way that makes sense to me because it seems like a lot of our adults with congenital heart disease also have other issues because of their congenital heart disease, so they may have liver issues. They may have kidney involvement. They may have immunological disease on top of their congenital heart disease, so it would seem to me that all of those other organs and additional problems might compromise their health and also consequently coronary artery disease. Does that make sense?

spk_1:   3:46
Yeah, that's absolutely right. I think one thing that we've come to realize is that congenital heart disease is certainly not restricted to the heart. It's very much a multi organ system disease. And one of the organ systems that is often affected is the kidneys. And the kidneys have a very unique role in controlling things like your blood pressure and that sort of thing. So what we do find is that people who have congenital heart disease there may be a higher risk of developing coronary risk factors such as hypertension such as diabetes such as metabolic syndrome. And that may play a role as well.

spk_0:   4:18
That all makes sense. Okay, so here's something else for us. Heart parents, too. I have to worry about when should we ask our Children's doctors to screen for coronary artery disease? Well, even if

spk_1:   4:31
we were to accept that people with CHD are at a higher risk for coronary disease in their peers, that's still exceedingly rare for coronary disease to present in childhood or adolescence. So Instead, what heart parents want to make sure their doctors are doing is to screen for the risk factors that will increase their Children's risk for coronary disease as they get older. So that means keeping track of the child's weight, their diet, their level of physical activity and then, as they get older, their blood pressure, their lipid levels and things like their use of tobacco products. So there's some specific situations where a cardiologists may want to more carefully evaluate the coronary arteries on earlier age. And one such situation would be someone who's had arterial switch operation complete transposition of the great arteries. And that's because during that surgery, what they do is they have to manipulate and relocate the coronary arteries. So there have been studies that show that there could be a greater potential for obstruction of the coronary arteries at an earlier age. Another situation might be a patient who has known coronary artery anomaly, so certain types of congenital heart disease are associated with coronaries coming off of unusual places. But because every patient is different, the best thing to do is to ask your cardiologists what sort of screening is appropriate for you or your child.

spk_0:   5:46
That makes sense now. Is coronary artery disease also genetic? If your parents have it, are you likely to get it now? That's an excellent

spk_1:   5:55
question. Probably one of the biggest risk factors for developing coronary disease is if there's a first degree relative who has developed coronary disease at an early age. That probably goes beyond the risk that you would get from high blood pressure and high cholesterol in that sort of thing. So we do know that there's certain risk factors that are strongly associated with the development of coronary disease. But there's also many things that we probably aren't aware of yet. So if you have a family member that has developed coronary disease at a very early age, especially a close family member, like a parent or a sibling, they're certainly going to be a higher risk that you'll have coronary disease as well, sometimes for reasons that we don't fully understand. Yet.

spk_0:   6:34
I wonder, too, though, if people who develop coronary artery disease early or earlier than their peers are because they're heavy smokers. And if a child is in a household where there's a big smoker, then they're exposed to second degree smoke and said that might compromise them in that way and or they might start smoking are laid themselves.

spk_1:   6:57
Absolutely. There's definitely environmental factors that are at play, things that are sometimes beyond the control of the child or the patient themselves. One thing that I will say is that the studies generally show that people who have congenital heart disease tend to have a lower rate of smoking than people without congenital heart disease.

spk_0:   7:15
Well, that's good to know.

spk_1:   7:18
I don't know what things are like in Texas or other parts of the country, but certainly here in New England. One thing that we're seeing much more commonly is that there's an increasing rate of people. I don't know if there's an increasing rate that people are using marijuana and vaping products, but they're certainly talking about it more frequently and talking about more openly. And that's one thing that unfortunately, we have very little data to support or to or to say that it does increase your risk of coronary disease. So I always have to tell people, you know, there's certainly no beneficial reason that we know of to be using those sorts of products, So it certainly makes sense to try to avoid anything that even has a potential for increasing your risk of coronary disease down the road.

spk_0:   7:57
That's really interesting. I saw that you had tweeted something about marijuana usage, and now that we have certain states that have legalized the uses of marijuana, I wonder if we're going to see increasing problems medical problems because of that.

spk_1:   8:12
Well, I've certainly seen people having heart rhythm problems that we think are related to marijuana use. Coronary disease is something that you're not going to see the effects of until many years later. So that's still something that we have to learn about. But now that it's becoming legal and may be easier for us to actually do studies on these sorts of things, says Previously, when marijuana was completely illegal, it was very difficult to do any studies. Looking at the long term effects of marijuana use and vaping is just such a new thing altogether that nobody's even thought about it until the last couple of years.

spk_0:   8:44
And from what I understand about vaping, it's much more variable than smoking cigarettes or marijuana because people have the option to Vape more or less nicotine or other products. They create their own stuff, so that's gonna be really challenging. To get any definitive studies from, we'll have one more quick question, and then we'll go to break. What symptoms should parents be aware of? That might be indicative of coronary artery disease.

spk_1:   9:11
Well, even though it's rare and younger patients doctors need to consider coronary artery disease any time a patient has chest pain or fainting, especially during exercise. Well, I want to be clear that chest pain is a very common symptom, and the cause is benign and the large majority of cases. But it's never the wrong thing to do to consult with your cardiologists or your child's cardiologists. Whenever there is a concern. By trying to get more details about the symptoms, doing a careful physical exam and getting an e, k G and maybe an echocardiogram, we can often make a determination about whether additional testing is necessary. And if we do have concerns, we may refer patients for things like CT angiography to better look at the coronary arteries or have him undergo a stress test to see if there's any evidence of blockage

spk_5:   9:54
takes this hot industry we're offering. That's a mechanical hot, and he said, now that I've had enough to give it to someone who's worthy My father promised me a golden dressed twirling held my hand and asked me where I wanted to go. Whatever stripe for conflict that we experienced in our long career together was always healed by humor.

spk_3:   10:14
Heart to heart With Michael Please join us every Thursday at noon, Eastern as we talk with people from around the world who have experienced those most difficult moments tonight forever by the Baby Blue Sound collective. I think what I love so much about this CD is that some of the songs were inspired by the patient's many listeners will understand many of the different songs and what they've been inspired by. Our new album will be available on iTunes. Amazon dot com. Spotify. I love the fact that the proceeds from this CD are actually going to help those with congenital heart defects enjoying music home

spk_0:   10:58
tonight forever good. Before the break, we were talking with Dr Wu about symptoms of coronary artery disease and the coronary artery disease presence in the CHD population. So what are some differences that we might see in coronary artery disease presentation in an adult with CHD. Compared to an adult who has a typical heart anatomy, there hasn't

spk_1:   11:24
been a lot of data about this. I would say that it's likely that we pick up a greater portion of these cases of coronary artery disease during the preoperative evaluation for unrelated heart surgery like valve Replacement. Then we wouldn't people without CHD simply because people with CHD are more likely to require heart surgery at an earlier age. Ah, then people without it. On the other hand, when someone with CHD presents primarily with shortness of breath, which sometimes is the primary manifestation of angina, it might be easier to assume that their symptoms are the result of their underlying congenital defect and miss the diagnosis of coronary disease.

spk_0:   11:59
Third,

spk_1:   12:00
I think certain patient groups, such as people who have undergone an arterial switch operation as we talked about before, may not present with typical symptoms of angina because the surgery involves alterations in the innovation of their heart. So they may present with symptoms more like shortness of breath or pain in an arm instead of chest pain. So we just have to be aware that there's certain patient groups where we have to be a little bit more vigilant about the potential for coronary disease.

spk_0:   12:26
And I think it's just something that we haven't really talked about much in the past, my sons in his twenties. But I know now that there are a lot of adults that are in Earth thirties, forties fifties sixties who were born with congenital heart disease. And so as our CHD population is aging, I think this is going to be something that we see more of, don't you?

spk_1:   12:47
Absolutely. And I think that's why, as you mentioned earlier, you're seeing more and more articles in the literature about the risks of coronary disease and what the risk factors are in this particular population.

spk_0:   12:57
My next question. I think you've already talked about a little, but I'm I'm so curious what you're gonna say. And that is what characteristics of congenital heart disease make. Treating coronary artery disease more complicated

spk_1:   13:10
as we talked about coronary disease can prison at an earlier age and it may be missed because of an atypical presentation or because we're distracted from the correct diagnosis by the patient's other cardiac issues. Also, many people with CHD have a typical anatomy, which could make angiography and perky Tania's interventions a lot more challenging, especially for cardiologists who aren't necessarily used to the lay of the land, so to speak. Sure, people with CHD by the time they reach adulthood, oftentimes have had two or three surgeries, or maybe even more so a vacuum ain't getting access particularly challenging if a coronary artery bypass surgery is needed. And in some CHD patients, the internal mammary arteries may have been coiled. Are coil included somewhere along the way, which means that we no longer can use those to perform bypass grafting. And in people without a history of congenital heart disease, those are usually the preferred types of graphs that we put in.

spk_0:   14:04
Oh my goodness, I hadn't thought of that. And then I would think to what you were talking about with those who were born with T G ET have had switch operations. What about people who were born with T. J. Who had a mustard or ascending? Is their anatomy going to make it more challenging if they do have coronary artery disease, people who have

spk_1:   14:25
had atrial switch operations. Like the muster, the sending usually don't have the same types of challenges in terms of getting to their coronary arteries. In those situations, it's it's actually a little bit different. The challenges that, because they're right ventricle is the systemic ventricle and takes on most of the workload. There may be some mismatch with the blood supply because most people 2/3 of your coronary blood flow, go to the left ventricle through the left anterior descending artery and the left sir complex artery, and about 1/3 goes to the right ventricle through the right coronary artery. So there have been studies that have shown that in people who have a systemic right ventricle, such as people who've had the atrial switch operations or people with congenitally corrected transposition, there may be evidence for ischemia. That's subclinical, meaning they don't have any symptoms. But when we do certain kinds of imaging, such as nuclear imaging, there may be inadequate blood flow to those parts of the heart because they're not built for sustaining that kind of pressure over a long period of time,

spk_0:   15:22
right? So they have their own problems that are different. That net

spk_1:   15:27
everyone's got their own set of problems.

spk_0:   15:29
Well, that's true whether you have congenital heart disease or not, wouldn't you say? Okay, considering the fact that we now have this aging CHD population due to the improvements in the treatment of congenital heart defects, is it reasonable for us to expect that we're going to see a growing population of a CH dears developing coronary artery disease?

spk_1:   15:50
I think it's exactly as you said. We've had well over one and 1/2 1,000,000 adults in the U. S. Living with congenital heart disease for some time now, and many, if not most of those individuals will develop coronary artery disease. Now what did they say? The first step is recognizing you have a problem, right? Once we've done that, then as a community, we can start to pay more attention to primary prevention of acquired cardiovascular disease rather than having our blinders on and getting too focused on just their congenital issues,

spk_0:   16:18
Right?

spk_1:   16:18
Studies do show that people with CHD maybe a higher risk for diabetes, high trackless rides, lower beneficial HDL cholesterol and a higher risk of metabolic syndrome compared to people without CHD. And for this reason, doctors and parents have a very important responsibility of in greening healthy habits and kids with CHD from a very early age. So that's more physical activity, less screen time, more fruits and vegetables, less sugar and process food. And then, as the kids get older, continually reinforcing the importance of a healthy lifestyle and talking to them about the dangers of tobacco and recreational drugs and things like that. So just like for the general population, prevention is the best strategy, and the earlier you start emphasizing prevention, the more effective your efforts are likely to be.

spk_0:   17:06
Absolutely. And I think the other thing is that parents have to lead by example.

spk_1:   17:10
That's absolutely true. Yes,

spk_0:   17:12
makes a big difference

spk_3:   17:20
to heart with Anna is a presentation of hearts, unite the Globe and is part of the hug Podcast Network Hearts Unite The Globe is a nonprofit organization devoted to providing resources to the congenital heart defect community to uplift and power and enrich the lives of our community members. If you would like access to free resource, is pretending to the C H T community, please visit our website at www congenital heart defects dot com for information about CHD, the hospitals that treat Children with CHD summer camps for CHD survivors and much, much more.

spk_5:   18:00
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spk_2:   18:32
You are listening to heart to heart with Anna. If you have a question or comment that you would like to dress down, show police in an email to Anna Dworsky at Anna at heart to heart with anna dot com. That's Anna at heart to heart with anna dot com Now back to heart to heart with Emma

spk_0:   18:51
Doctor Well before the break, we were talking about how we can prevent coronary artery disease in a congenital heart defect community, but now

spk_3:   18:59
we

spk_0:   18:59
have our live studio audience with us if you belong to the heart to heart with an A V i P group on Facebook. Then you can also be part of a live studio audience in the future. So join the heart tart with an A V i P group on Facebook. But now I have an audience here, and so we're going to open the floor to our audience, and I have an who will be asking her first question. So hey, hi, Welcome to Heart or Madonna.

spk_4:   19:27
I'm glad to be here. I'll just introduce myself and say that I'm definitely part of the aging population of people with CHD. I have congenitally corrected transposition of the Great Arteries. I was born in 1953 and I actually was followed at Children's Hospital and received my first pacemaker at age 10 in 1963. And for a long time we thought that I was the longest surviving person with a pacemaker. Wow, I'm not on the second, which I found out by publishing a daily blogged where I blogged about CHD as well as other things. So it's great to be talking to you today. My question has to do with the fact actually that with C c T g A. What I've noticed with myself, and I'm not sure this is true with other people with C C T g. A. Is that I have very low blood pressure. I don't know if that's typical for people with C C T g A. And I'm wondering if that makes me less likely to have coronary artery disease.

spk_1:   20:29
Yeah, as you point out, everybody with congenital heart disease is, ah, very unique individual people with C C T G. A sort of span the whole gamut. There's people with C C T. J who have never needed any heart surgery and their 70 years old now on, and they were just diagnosed for the first time. And then there's people who have C, C, T J and multiple other anomalies associate with that. So they've had to go through multiple surgeries and pacemaker placements, so it's it's hard to make a general statement about that. What I can tell you is that again, most of the studies suggest that hypertension happens at a pretty similar rate, if not at a higher rate, and people who have congenital heart defects, including those with complex congenital heart defects than people in the general population. Sometimes there are things that can cause the blood pressure to be lower in particular individuals. So sometimes we do see people who have single ventricle, and they may have a situation where there systemic vascular resistance runs low and the blood pressure runs low. We don't really know at this point what that means in terms of their long term risk of coronary disease. But what I can tell you is that based on knowledge from the general population, for the most part, the lower your blood pressure is as long as you're asymptomatic, the lower your long term risk of heart attacks and strokes and heart failure. So it's actually a good thing.

spk_4:   21:43
Yeah,

spk_1:   21:43
there is what we call it a J curve, meaning that if the blood pressure gets very low, then we start seeing increasing mortality. And that's usually because that means that when your blood pressure's very low, there's some other condition that's causing your blood pressure to run that low, and that may be affecting your long term mortality. So if your systolic blood pressure tends to run in the nineties, or between 101 10 I would say that's actually a very good thing. As long as you're not experiencing light headedness or fatigue or shortness of breath with activity, and that may be reducing your long term risk of corn, your disease. It's hard to say,

spk_4:   22:16
and that's exactly where I am. So I think I'm in the sweet spot. Absolutely. The question that I thought of ahead of time was I actually had heart surgeries to implant the pacemaker. But I've never had open heart surgery until a few years ago, where I had a valve replaced man, a leaky bell, which I said, you know, which is a pretty common by product of C C T g. A. And two days before the surgery, they, cath, arise me to see how I was in terms of arteries. I was hoping that I would have ah clean bill of health for that, and I did good, and I wondered, What would they have done if they did find coronary artery disease when they did that? Catherization

spk_1:   23:01
Yeah, that's a good question. So So as we had mentioned earlier in the podcast, typically, when a patient who is about 40 years of age earlier undergoes any kind of heart surgery. We will look at the coronary arteries ahead of time, and that's one of the times when we might identify Korean, your disease and somebody who's completely asymptomatic. And what we do, based on what we find, really depends on how bad the coronary disease is. So if we find just a mild areas of narrowing, we wouldn't do any kind of stenting or bypass surgery for that particular level of corn ear disease. But that does sort of pushed us to be a little bit more aggressive about treating risk factors, like maybe putting somebody on a staten toe, lower their cholesterol or treating their blood pressure a little bit more aggressively. If there's more severe narrowing, even if the patient is asymptomatic, then we may actually do a bypass graft at the same time that we're doing the valve surgery and we have done that before where we sort of do a combined operation.

spk_0:   23:55
Wow, that was a great question and I think that you adults with complex congenital heart disease who are ageing, especially once you hit 50 because I think personally when I hit 50 they started to really change and I started to feel a lot older. I could tell that my organs had been around for five decades. Let's put it that way.

spk_4:   24:18
I'll tell you one of the advantages of being born with something like C C T G A. Is that I don't feel any worse now than I felt what I was. That's fantastic. I feel great. I walk two miles every day and I'm waiting to slow down. And that hasn't happened to me yet.

spk_0:   24:37
But don't just don't

spk_1:   24:39
say I'll tell you I think I think the exercise, the walking two miles a day is probably the very best thing that you can do for yourself in the long term. And I think that goes for everybody with congenital heart disease. Should be making regular exercise. Ah, part of their daily activities.

spk_0:   24:52
Yeah, I think that does make a difference. Absolutely, Doctor would one of our V i P members couldn't be here, but she asked me if I would ask a question to you. And okay, so she wants to know if all people with C C t g a Onley have one coronary artery for their main heart pump their right ventricle, she said she has C C T G A. And she only has one coronary artery for her right ventricle.

spk_1:   25:19
Correct. That's sort of what we had discussed earlier. Is that in people who have C C T G A. Basically, what happens is that you get the right coronary artery, which supplies the right ventricle. And then there's the left coronary arteries, which comprises the left anterior descending on the left, sir complex, which supplies the left ventricle. So that is something that has been a bit of ah, problem, I guess you could say, or a struggle in people who have systemic right ventricle. We don't really know what the long term consequence of that will be, but, you know, as as we sort of talked about, there's many people who have C C T G A. And they operate on one coronary artery going to that right ventricle, and they may not have any problems in the long term. So it is a typical arrangement for people with C C T g. A. But whether that's a long term problem or not, I don't think we're completely sure of at this point.

spk_0:   26:06
Okay, Then she had another question, and clearly this is something that has concerned her because she's out there doing more research, she said. Dr. Carroll warrants from the Mayo a CHD explained in a 2012 webinar titled Aging with C. C T G. A. That due to this issue that may cause exercise incompetence in ischemia. And, Sally said, Can you explain more about the implications of one coronary artery for those individuals and how it affects them in their daily life?

spk_1:   26:40
So usually because the left ventricle does the most work, it sort of makes sense that the left ventricle usually has the two coronary arteries and the larger part of the coronary blood flow. Because when you're working harder and your heart muscle is working harder as well, it requires more fuel in the form of blood flow and oxygen. If there's only one coronary arteries supplying your systemic ventricle, that does the raise the concern that when you're working very hard and your heart muscle demands more oxygen, that you may not be able to get the amount of oxygen that's necessary, and when the heart muscle is not getting adequate oxygen, that's what we call ischemia, so one of the theories about the potential long term development of ventricular dysfunction and people who have C c T G a. Meaning that it in some people, as they get older, the right ventricular function will start to decrease. One of the theories is that maybe because of this sort of subclinical ischemia over many, many years. So even though people may not be complaining of a lot of just being a shortness of breath when they exercise, if there is a very small amount of damage that causes heart muscle to get injured and become fiber Roddick. And if that builds up over many, many years, that can slowly cause the ventricular function to decrease the advance in studies where they've done nuclear imaging, meaning that they inject a nuclear contrast into a patient and then look at that with a radioactive camera. And what they found is that in some people with a systemic right ventricle, there are areas that seemed to get inadequate blood flow during stress. But at this point, we don't really know what we can do about that and how important that is in terms of the long term development of heart failure, But what doctor warns was talking about in terms of exercise, limitation or exercise. Intolerance is that if you do get inadequate blood flow to your heart muscle, usually what happens is patients will start to feel short of breath. Or they may feel chest discomfort that causes them to slow down so that they can't exercise to the same level as they would be able to without a coronary issue.

spk_0:   28:34
I think Anne has another question. So I'm gonna invite an back sure to be alive

spk_4:   28:40
again next. This is going to be a lot more relevant to me than I expected. And one thing that I've noticed what C. C T. G a. Is that I always hate going upstairs or walking up a hill when I've actually gotten together with other people that have C c T g A. They described a similar experience, So now it's occurring to me that perhaps that has to do with the fact that I have only one coronary artery going to that ventricle, which I never knew until today. So I'm just wondering if that's an explanation. It's certainly food for thought. For me,

spk_1:   29:17
it's possible there's lots of things that are unique about C. C T J circulation that can affect your ability to do more strenuous activities like climbing hills or climbing stairs. So you talk about one, which is the coronary artery mismatch, sort of with the amount of work that the vegetables have to do. There's the other issue, which you sort of alluded to a swell, which is that heart block is a very common problem for people with C C T G A. So that develops out about a rate of 2% per year, and you can fix that to some degree by putting in a pacemaker. But pacemakers are not nearly as good as your natural conduction system. And then the other thing, too, is that, you know, when you put in a pacemaker, this gets into a whole other complex situation. When you put in a pacemaker, you're stimulating a contraction of your ventricles, but you're stimulating the ventricles from an abnormal place that's not following the usual conduction system, so that also affects the synchronicity of the heart squeeze. And we do think that for some people that can actually impact their ability to exercise and impact their heart function over the long term. And that's one of the reasons why you may have heard about people getting these re synchronization devices, meaning that they get not just one wire going to the ventricles. But they may have two or even three to try to get the ventricles to squeeze in a more coordinated fashion. And that's another reason why somebody who's had a pacemaker might find that they have more trouble doing more strenuous activities.

spk_0:   30:39
You know, all of that makes sense. Wow, I have one more question from a V I P member who couldn't be here, and she said, Is there any progress for people with C C T G. A and getting a bi ventricular pacemaker placed, she said. Because of their hearts anatomy, she was told that they may have to collapse her lung to go through her ribs to add 1/3 lead. And she said, some people with C C T. G. A don't have to experience that. So she's wondering if doctors are working to make this a less painful experience for those with C C T. G. A.

spk_1:   31:12
Well, you have a lot of C C T J listeners. It's oh

spk_4:   31:14
No, I'm shocked. Maybe this is turning into

spk_0:   31:17
the C C T. G. A coronary artery show

spk_1:   31:21
today is I mean, it's It's certainly a very unique and interesting type of congenital heart disease on its own. That is something that we've thought about again because there's this issue that complete heart block is a common problem. And because we've known from patients who have normal anatomy, who need pacemakers that pacing the ventricle over many, many years from an abnormal place can actually lead to the ventricular functioning declining. There's been a lot of thought about when we do need to put in a pacemaker. How do we put it in such a way that the conduction occurs as normally as possible and therefore will reduce their long term risk of developing ventricular dysfunction? And one way that you can do that is with these re synchronization devices in most people and people with the usual anatomy, the way we put in that additional lead is we snake a wire through what we call the coronary veins. So where the blood that's gone through the heart muscle through the coronary arteries ends up coming back again to the right atrium, it comes back through a coronary Sinus. So what the electro physiologist can do is they can try to snake a wire into that coronary Sinus and down a coronary vain. And they're trying to find a location where they can place a leave that will stimulate the left side of the heart so that you have one wire in the right ventricle and then one wire that simulates left ventricle. So by stimulating both sides of the heart, you create a more coordinated squeeze in people who have C C T G. A. The problem is that their coronary Venus anatomy oftentimes, is abnormal. So often times it's not practical or maybe even possible, to get a wire down the vein and stimulate the left ventricle. That way, in order to do the cardiac re synchronization procedure, where you seemingly both ventricles, oftentimes what they have to do is they have to do a thoracotomy, meaning that they go through the side of the chest. They collapsed the lung so that they can actually see what they're doing without the lung on the way, and then putting wires in on the outside of the heart on both sides. on the left ventricle and the right ventricle so that both sides of the harder stimulated at the same time, that, as you can imagine, is a much bigger production than doing it through the trans venous approach that we do for most people. I don't think everybody is doing it that way. As the initial approach, there has been some talk recently about people doing something called bundle of hiss pacing, meaning that they try to get the wire higher up on the ventricular septum closer toe, where the normal conduction system lies so that the conduction system will do most of the work so that instead of having the electrical impulse travel through the heart muscle that goes through the normal conduction system. And that can lead to a narrower Q R s complex on E K G, which we think also will reduce the long term risk of ventricular dysfunction. Now, whether you can do that in somebody with C. C. T G, I think is much more questionable. It's gonna be a lot more challenging, but that is something I know that electro physiologist have been trying to look at.

spk_0:   34:00
Wow, it just gets so complicated And then if you have C c T G a horse who have had radiofrequency ablation anywhere near there, that could cause problems to worry.

spk_1:   34:11
Yeah, I'm the one of the problems. Is that and people who've had a lot of ablation procedures, You know there's more scar tissue because what you're doing in an ablation procedures, you're creating lines of scar to try to prevent re entrant rhythms or short circuits from occurring. So certainly, if you have scar, that's going to impact the way that the conduction occurs in the heart tissue, and that just complicates things further. But most people with C T G A haven't had ablation in their ventricle anyway. Well, sometimes do that for people who have been trickle attacking cardia. But in terms of cardiac re synchronization therapy, I think the ablation is less of an issue. It's really more the abnormal anatomy in the abnormal coronary Venus anatomy that makes re synchronization more challenging.

spk_0:   34:51
I'm just amazed at everything that you doctors know and how you're able to circumvent problems like this and come up with new solutions. It's really quite amazing.

spk_1:   35:01
Medicine has gotten to a point where it's very complicated And that's why you do see people who become very specific specialist. So for this type of thing, often times we will refer our patients to the electro physiologist that we work with because they do things that are just so complicated that it's certainly above my pay grade, you know, stuff that I don't fully understand. So it's very important for your cardiologists to work as a team. You know, you have your doctors that see you in the clinic, you have the surgeons, you have the electro physiologist that handled the conduction system and the heart rhythm problems. And you have the interventional ist that have been doing incredible things using stems and trance, catheter, vowels and all sorts of things that make it easier for us to fix things without actually having to go through an open heart surgery anymore.

spk_0:   35:43
That's what I love. I love the fact that interventional cardiology seems to be growing and blossoming, and we are able to do more without actually having to open the chest.

spk_1:   35:52
It's absolutely mind boggling. The things that we've learned to do in the last 10 or 15 years.

spk_0:   35:58
It is well, thank you so much for coming on the show today, Dr Wu, and for sharing your knowledge about coronary artery disease. I appreciate you coming on the show and sharing your knowledge with us because doctors who can make it understandable to the common people You're so valuable. There are so many doctors who just talk right over our heads, and we find it intimidating to ask the questions that we need to ask it. Clearly, this is something that we need to be talking about.

spk_1:   36:24
Yeah, absolutely. And you know, I think a lot of patients do get a little bit nervous about asking too many questions in their clinic appointment, but I think you absolutely should. Most doctors, especially congenital heart disease doctors, absolutely welcome questions. So if you have any, don't hesitate to ask your doctor at all

spk_0:   36:39
well. And hopefully people are listening to this program, and they're starting to understand what they can ask about and what they should be worried about and shouldn't be worried about. I mean, it seems to me like coronary artery disease is something that we need to be aware of, but not necessarily terribly worried about. What we need to be worried about is are we providing nutritious meals for our kids? Are we setting a good example? Are we telling them not to smoke and not smoking ourselves so they don't get into that habit and just to be aware that they could be a greater risk? Am I right about that?

spk_1:   37:09
Right. I think the general cardiology community has been very good at getting the message out there. And I think most people know what is good for them and what isn't good for them. And if you start paying attention to that at a very early age, it will certainly have a beneficial effect on your health in the long term.

spk_0:   37:24
That does conclude this episode of Hart to Hart within it. Thank you for listening today, thanks to my studio audience, you all were awesome. Please find us on our website hearts. Unite the globe dot or ge And remember, my friends, you are not alone.

spk_2:   37:41
Thank you again for joining us this week Way Hope you have been inspired on Empowered to become an advocate for the congenital heart defects community Heart to heart with Anna with your hose down, Jaworski can be heard every Tuesday at 12 noon eastern time